Atlas drenaje ganglionar

1. Special Report
Rafael Martinez-Monge, MD
Patrick S. Fernandes, MD
Nilendu Gupta, PhD
Reinhard Gahbauer, MD
Index terms:
Computed tomography (CT),
three-dimensional, 99.12917,
99.92
Lymphatic system, 99.12917, 99.92
Special reports
Treatment planning, 99.92
Radiology 1999; 211:815–828
Abbreviations:
CTV ϭ clinical target volume
GTV ϭ gross tumor volume
3D ϭ three-dimensional
Cross-sectional Nodal Atlas:
A Tool for the Definition of
Clinical Target Volumes in
Three-dimensional Radiation
Therapy Planning1
Virtual three-dimensional clinical target volume definition requires the identification
of areas suspected of containing microscopic disease (frequently related to nodal
stations) on a set of computed tomographic (CT) images, rather than the traditional
approach based on anatomic landmarks. This atlas displays the clinically relevant
nodal stations and their correlation with normal lymphatic pathways on a set of CT
images.
1
From the Division of Radiation Oncology, the Arthur G. James Cancer Hospital,
Ohio State University, 300 W Tenth Ave,
Columbus, OH 43210. Received July 15,
1998; revision requested August 27;
revision received October 16; accepted November 23. Address reprint requests to R.M.
௠ RSNA, 1999
When radiation is used with curative intent, the radiation volume usually encompasses the
detectable tumor and the anatomic areas thought to be at risk for metastatic spread. The
International Commission on Radiation Units and Measurements Report No. 50 (1) defines
gross tumor volume (GTV) as the gross palpable or visible or demonstrable extent and
location of the malignant growth. The same report defines clinical target volume (CTV) as a
volume that contains a demonstrable GTV and/or is considered to contain (only)
microscopic, subclinical extensions at a certain probability level. In clinical practice, the
determination of the extent of the CTV is based on the knowledge of the patterns of spread
for each specific disease presentation. Additional reliable information can be obtained from
patterns-of-failure analysis and necropsy series.
For most tumors, the CTV will encompass one or more nodal stations, usually near the
primary lesion. Traditionally, the location and boundaries of these nodal stations have
been established in reference to anatomic landmarks during the standard simulation setup.
Therefore, the radiation oncologist has been specifically trained to determine the boundaries of the different nodal stations on standard two-dimensional radiographs, especially in
the anteroposterior and posteroanterior views. With the advent of three-dimensional (3D)
virtual clinical target definition, the radiation oncologist faces the challenge of defining
the CTV on cross-sectional CT or magnetic resonance images. Unfamiliarity with this new
technique can make correlations with the known spatial references difficult to establish.
The present nodal atlas is intended to assist radiation oncologists who will use new 3D
virtual clinical target definition and treatment planning programs.
CLASSIFICATION AND NOMENCLATURE
Author contributions:
Guarantor of integrity of entire study,
R.M., R.G.; study design, R.M.; definition of intellectual content, R.M.; literature research, R.M., P.S.F.; data
acquisition and analysis, R.M., N.G.;
manuscript preparation, R.M.; manuscript review, R.G.
The anatomic patterns of lymphatic drainage for different organs to their first echelon (or
efferent) nodal stations were taken from Rouviere’s Anatomy of the Human Lymphatic System
(2) and confirmed with other lymphatic anatomy textbooks (3,4). The main and accessory
lymphatic routes for different organs that are relevant in radiation oncology are summarized in Tables 1–8, with an explanation of the abbreviations appearing in the Key Box.
When different subsites within an organ had unique drainage patterns, these were
individualized in the Tables as well. The classification of and nomenclature for the different
nodal areas usually followed the guidelines of Rouviere’s system (2). In the classification of
the mediastinal nodes, the widely used American Joint Committee on Cancer classification
815

2. Key Box for Abbreviations in Tables and Figures
Abbreviation
APWN
ATL
AxN
BTL
CIN
CN
CPN
DN
EIN
GL
HMN
HN
HPL
IGL
IIN
IJN
IMN
IN
IPN
IRN
JVN
LCP
LGN
LPN
LRH
LUP
MN
NL
PAN
PAuN
PCL
PecN
PEN
Nodal Group
Abbreviation
Aortopulmonary window nodes
Anterior tongue lymphatics
Axillary nodes
Base tongue lymphatics
Common iliac nodes
Celiac axis nodes
Cervical pretracheal nodes
Diaphragmatic nodes
External iliac nodes
Glottic lymphatics
High mediastinal nodes
Hepatic nodes
Hard palate lymphatic plexus
Infraglottic lymphatics
Internal iliac nodes
Internal jugular nodes
Internal mammary nodes
Superficial inguinal nodes, deep inguinal
nodes
Internal pudendal nodes
Inferior rectal nodes
Juxtavertebral nodes
Left cervical paratracheal nodes
Left gastric nodes
Left paraaortic nodes
Left renal hilum nodes
Left upper paratracheal nodes
Mastoid nodes
Nasopharyngeal lymphatic plexus
Preaortic nodes
Preauricular nodes
Postcricoid lymphatic plexus
Pectoral nodes
Paraesophageal nodes
PFL
PG&N
PHN
PL
PLN
PPL
PRL
PSL
PsRN
PiL
PTrN
PVgL
PVL
PVsN
RAN
RCP
RRH
RLP
RPN
RUP
SAN
ScIN
SCN
SGL
SMaN
SMeN
SMN
SN
SPL
SplN
SRN
SVL
TL
Nodal Group
Pyriform fossa lymphatics
Parotid gland and nodes
Hilar nodes
Parametrial lymphatic plexus
Prelaryngeal nodes
Periprostatic lymphatic plexus
Perirectal lymphatic plexus
Paranasal sinuses lymphatics
Superior posterior pharyngeal wall lymphatics and retropharyngeal nodes
Inferior posterior pharyngeal wall lymphatics
Mediastinal pretracheal nodes
Paravaginal lymphatic plexus
Perivesical lymphatic plexus
Prevascular nodes
Retroaortic nodes
Right cervical paratracheal nodes
Right hilum renal nodes
Right lower paratracheal nodes
Right paraaortic nodes
Right upper paratracheal nodes
Spinal accessory nodes
Supraclavicular nodes
Subcarinal nodes
Supraglottic lymphatic plexus
Submandibular nodes
Submental nodes
Superior mesenteric nodes
Sacral nodes
Soft palate lymphatics
Splenic nodes
Superior rectal nodes
Seminal vesicles lymphatic plexus
Tonsil lymphatic plexus
TABLE 1
Head and Neck Lymphatic System (I)
was chosen instead (5). The nodal areas
represented are listed in the Key Box.
When clinically relevant, some nodal stations were further divided into subgroups, which are noted as lowercase
letters after the abbreviation codes provided in the Tables and the Figures. The
nonparenthesized lowercase letters indicate differentiated subgroups, usually in
the direction of the zzЈ axis. Parenthesized letters indicate subgroup subdivision, usually in the direction of the xxЈ
axis (shown only for inguinal and external iliac nodes).
LOCALIZATION OF NODAL
STATIONS
The different nodal stations were outlined and labeled on five different sets of
consecutive and equidistant CT images
(head and neck, thorax, abdomen, male
pelvis, and female pelvis) (Figs 1–6). We
elected to use CT images because they are
the customary image support in most 3D
virtual clinical target definition programs. The nodal stations on the crosssectional images were localized by ex816 • Radiology • June 1999
Anatomic Site
Lacrimal gland
First Echelon Nodal Group
Preauricular nodes
Parotid nodes
Submandibular nodes
Eyelids, conjunctiva
Preauricular nodes
Parotid nodes
Submandibular nodes
Pinna
Preauricular nodes
Parotid nodes
Mastoid nodes
Internal jugular nodes
External auditory canal
Parotid nodes
Internal jugular nodes
Middle ear
Preauricular nodes
Retropharyngeal nodes
Internal jugular nodes
External nose
Submandibular nodes
Nasal cavity
Retropharyngeal nodes
Internal jugular nodes
Paranasal sinuses
Retropharyngeal nodes
Internal jugular nodes
Lip, upper
Submandibular nodes
Submental nodes
Preauricular nodes
Lip, lower
Submandibular nodes
Submental nodes
Cheek, cutaneous
Submandibular nodes
Submental nodes
Parotid nodes
Buccal mucosa
Submandibular nodes
Tongue, apex
Submental nodes
Internal jugular nodes
Tongue, lateral and posterior Submandibular nodes
Internal jugular nodes
Subgroup
Category Abbreviation
Main
Main
Main
Main
Main
Main
Main
Main
Main
Upper
Main
Main
Upper
Main
Main
Main
Upper
Main
Main
Main
Upper
Main
Main
Upper
Main
Main
Accessory
Accessory
Main
Main
Main
Main
Main
Main
Main
Upper, middle Main
Main
Upper
Main
PAuN
PG&N
SMaN
PAuN
PG&N
SMaN
PAuN
PG&N
MN
IJNu
PG&N
IJNu
PAuN
PsRN
IJNu
SMaN
PsRN
IJNu
PsRN
IJNu
SMaN
SMeN
PAuN
SMaN
SMeN
SMaN
SMeN
PG&N
SMaN
SMeN
IJNu, m
SMaN
IJNu
Martinez-Monge et al

3. Figure 1. CT images depict head and neck nodal stations at levels hn01 through hn09 on the topogram in Figure 7.
Volume 211 • Number 3
Cross-sectional Nodal Atlas for Definition of Clinical Target Volumes • 817

4. TABLE 2
Head and Neck Lymphatic System (II)
Anatomic Site
Floor of mouth
Lower gum
Upper gum
Hard palate, soft
palate inferior
Soft palate, superior
Tonsil
Nasopharynx
Pyriform fossa
Posterior cricoid
Posterior pharyngeal
wall, superior
Posterior pharyngeal
wall, inferior
Supraglottic larynx
Infraglottic larynx
Trachea
Thyroid
Parotid gland
Submandibular gland
Sublingual gland
trapolating information from crosssectional anatomy atlases (6), lymphatic
atlases (3), and vascular atlases (4). To
allow easy correlation, the five sets of CT
images were connected with a recognizable bone structure on a topogram (Fig 7).
REPRESENTATION OF THE
ANATOMY OF THE LYMPHATIC
SYSTEM IN THE NODAL ATLAS
The initial lymphatic system is composed
of capillary lymphatics, which originate
in the intima of the tissue and are immersed in the ground substance of the
tissue space. These capillaries anastomose
in networks to form the peripheral lym-
818 • Radiology • June 1999
First Echelon Nodal Group
Submental nodes
Submandibular nodes
Internal jugular nodes
Submandibular nodes
Submental nodes
Internal jugular nodes
Submandibular nodes
Retropharyngeal nodes
Internal jugular nodes
Submandibular nodes
Retropharyngeal nodes
Retropharyngeal nodes
Internal jugular nodes
Internal jugular nodes
Retropharyngeal nodes
Internal jugular nodes
Spinal accessory nodes
Internal jugular nodes
Internal jugular nodes
Retropharyngeal nodes
Internal jugular nodes
Internal jugular nodes
Internal jugular nodes
Internal jugular nodes
Cervical pretracheal nodes
Prelaryngeal nodes
Cervical pretracheal nodes
Cervical paratracheal nodes
Prelaryngeal nodes
Cervical pretracheal nodes
Cervical paratracheal nodes
Internal jugular nodes
Retropharyngeal nodes
Parotid nodes
Submandibular nodes
Submandibular nodes
Internal jugular nodes
Submandibular nodes
Internal jugular nodes
Subgroup
Upper, middle
Upper, middle
Upper
Upper
Upper
Upper
Upper, middle
Upper, middle
Upper
Middle
Upper, middle
Middle, lower
Cervical
Cervical
Cervical
Cervical
Cervical
Upper, middle,
lower
Upper
Upper
Category
Abbreviation
Main
Main
Main
Main
Main
Main
Main
Main
Main
Accessory
Accessory
Main
Main
Main
Main
Main
Main
Main
Main
Main
Main
Main
SMeN
SMaN
IJNu, m
SMaN
SMeN
IJNu, m
SMaN
PsRN
IJNu
SMaN
PsRN
PsRN
IJNu
IJNu
PsRN
IJNu
SAN
IJNu, m
IJNu, m
PsRN
IJNu
IJNm
Main
Main
Main
Main
Main
Main
Accessory
Main
Main
Main
IJNu, m
IJNm, l
CPN
PLN
CPN
LCP, RCP
PLN
CPN
LCP, RCP
IJNu, m, l
Accessory
Main
Main
Main
Main
Main
Main
PsRN
PG&N
SMaN
SMaN
IJNu
SMaN
IJNu
phatic plexuses. These plexuses are only
represented in the atlas for certain organs
that are frequently irradiated while intact
(prostate, rectum, some head and neck
subsites, etc) to facilitate the recognition
of the organ or site and its spatial relationship with the surrounding nodal stations.
The lymphatic plexuses drain to the
first echelon lymph nodal stations
through precollecting and collecting
ducts. Sometimes, there are intercalating
lymph nodes in the path of the collecting
ducts. In general, no intermediate paths
between the organ of interest and the first
echelon nodal station have been represented in the atlas to avoid unnecessary
complexity. However, some clinically relevant intercalating nodes have been rep-
resented (superior and inferior rectal
nodes and internal pudendal nodes).
The first nodal station reached by the
lymphatic drainage of a given organ is
called the first echelon nodal group. The
first echelon lymph nodes connect to
each other through postlymphonodal collecting ducts and finally drain to more
central efferent lymph nodes or directly
into the venous system through the main
lymphatic trunks, depending on anatomic location. As a rule, the first echelon
nodal stations for all the different organs
of the head and neck, thorax, abdomen,
and pelvis are represented. These are listed
in the Tables 1–8. One exception to this
rule has been the case of the small bowel
and most of the large bowel. Due to the
Martinez-Monge et al

5. Figure 2. CT images depict head and neck nodal stations at the levels hn10 through hn18 on the topogram in Figure 7.
Volume 211 • Number 3
Cross-sectional Nodal Atlas for Definition of Clinical Target Volumes • 819

6. TABLE 3
Thoracic Lymphatic System
Anatomic Site
Lung; RUL anteromedial
Lung; RUL posterolateral, RML, RLL
superior
Lung; RLL inferior
Lung; LUL superior
Lung; LUL inferior,
LLL superior, LLL
middle
Lung, LLL inferior
Costal pleura,
superior
Costal pleura,
middle
Costal pleura,
inferior
Right diaphragm,
subperitoneal
Left diaphragm,
subperitoneal
Right and left diaphragm, subpleural
Breast
anatomic mobility of these organs, the
efferent pre- and paraaortic nodal groups
(fixed structures with reproducible location), rather than the first echelon nodal
groups (juxtaintestinal and paracolic), are
represented in the atlas. Patterns of
anomalous nodal spread, such as retrograde spread, are not shown in this atlas.
ERRORS IN LOCALIZATION
OF NODAL STATIONS
Lymphography is the technique of choice
to visualize nodal groups. However, its
decline in the field of diagnostic radiol-
820 • Radiology • June 1999
Category
Abbreviation
Right paratracheal nodes
First Echelon Nodal Group
Upper, lower
Subgroup
Main
RUP, RLP
Right paratracheal nodes
Right hilar nodes
Subcarinal nodes
Right hilar nodes
Subcarinal nodes
Left upper paratracheal
nodes
Prevascular nodes
Aortopulmonary window
nodes
Left upper paratracheal
nodes
Prevascular nodes
Aortopulmonary window
nodes
Left hilar nodes
Subcarinal nodes
Left hilar nodes
Subcarinal nodes
Supraclavicular nodes
Internal jugular nodes
Juxtavertebral nodes
Internal mammary nodes
Axillary nodes
Juxtavertebral nodes
Internal mammary nodes
Diaphragmatic nodes
Retroaortic nodes
Paraesophageal nodes
Retroaortic nodes
Diaphragmatic nodes
Paraesophageal nodes
Retroaortic nodes
Axillary nodes
Internal mammary nodes
Supraclavicular nodes
Pectoral nodes
Upper, lower
Main
Main
Main
Main
Main
Main
RUP, RLP
PHNr
SCN
PHNr
SCN
LUP
Main
Main
PVsN
APWN
Main
Main
Main
Main
Main
LUP
PVsN
APWN
PHNl
SCN
Main
Main
Main
Lower
Main
Any level
Main
Any level
Main
Main
Any level
Main
Any level
Main
Right lateral
Main
Suprarenal, thoracic Main
Inferior
Main
Suprarenal, thoracic Main
Main
Anterior, lateral
Main
Inferior
Main
Suprarenal
Main
Any level
Main
Accessory
Accessory
ogy has led to the decline of its use as a
tool for radiation therapy planning, and
it has been virtually abandoned for both
purposes. However, currently used standard radiation ports still follow the boundaries determined during the lymphographic era. During standard simulation,
the different nodal stations are not actually seen on the simulation radiographs;
therefore, a margin of normal tissue is
taken around the CTV to allow for any
localization uncertainties. Three-dimensional virtual clinical target definition,
like standard simulation, lacks visualization of nodal stations. However, because
localization errors on cross-sectional im-
PHNl
SCN
SclN
IJNl
JVNs, m, i
IMNs, m, i
AxN
JVNs, , m, i
IMNs, m, i
DNlat
RANsr, t
PENi
RANsr, t
DNa, lat
PENi
RANsr
AxN
IMNs, m, i
SclN
PecN
ages are minimized (as are the associated
increases in CTV uncertainty and size of
the planning taget volume), this problem
is not as great. During 3D virtual clinical
target definition, only a few of the nodal
stations represented in the atlas are visible on a CT image. So, the exact location
of a given station in an individual is
difficult to determine. Furthermore, the
internal structure of the lymphatic system (different normal variants among
subjects) precludes any categorical statement (2–4). Therefore, we chose to outline wide areas rather than discrete locations for each nodal station to account
for the differences in normal anatomic
Martinez-Monge et al

7. Figure 3. CT images depict the nodal stations in the thorax (th).
Volume 211 • Number 3
Cross-sectional Nodal Atlas for Definition of Clinical Target Volumes • 821

8. TABLE 4
Gastrointestinal Lymphatic System (I)
Anatomic Site
First Echelon Nodal Group
Gastric cardia
Left gastric nodes
Gastric lesser cur- Left gastric nodes
vature
Gastric antrum
Hepatic nodes
and pylorus
Greater omentum Hepatic nodes
Gastric greater
curvature
Duodenum
Pancreas
Spleen
Liver
Gallbladder and
cystic duct
Hepatic duct
Common bile
duct
Splenic nodes
Subgroup
Category Abbreviation
Juxtacardiac
Gastropancreatic
Lesser curvature
Right gastroepiploic
Infrapyloric
Suprapyloric
Right gastroepiploic
Infrapyloric
Suprapyloric
Suprapancreatic
Hepatic nodes
Main
Main
Main
Main
Main
Main
Main
Main
Main
Main
Postpancreaticoduodenal
Main
Main
Main
Main
Main
Main
Main
Main
Main
Main
Main
Main
Main
Main
Main
Main
Main
Main
Main
Main
Main
Main
Main
Main
Main
Main
HNp
HNp
HNpd
SMN
HNp
HNpd
HNha
SplNs
SplNh
LGNlc
SMN
SMN
SMN
RPNs
LPNs
SplNh
HNha
CN
LGNlc
DNa, lat
PENi
RRH, LRH
HNha
HNha
HNha
HNha
Main
Infrapyloric
Retropyloric
Pancreaticoduodenal
Superior mesenteric nodes Postpancreaticoduodenal
Hepatic nodes
Infrapyloric, suprapyloric
Pancreaticoduodenal
Hepatic artery
Splenic nodes
Suprapancreatic
Splenic hilum
Left gastric nodes
Gastropancreatic
Superior mesenteric nodes Root of mesentery
Middle colic
Postpancreaticoduodenal
Right paraaortic nodes
Superior
Left paraaortic nodes
Superior
Splenic nodes
Splenic hilum
Hepatic nodes
Gallbladder, hepatic artery
Celiac axis nodes
Left gastric nodes
Lesser curvature
Diaphragmatic nodes
Anterior, lateral
Paraesophageal nodes
Inferior
Renal hilum nodes
Hepatic nodes
Gallbladder
Foramen of Winslow
Hepatic nodes
Foramen of Winslow
Hepatic nodes
Foramen of Winslow
LGNc
LGNlc
LGNlc
HNrg
HNp
HNp
HNrg
HNp
HNp
SplNs
HNpd
TABLE 5
Gastrointestinal Lymphatic System (II)
Anatomic Site
Jejunum, ileum
Cecum and appendix
Ascending colon
Transverse colon, right
Transverse colon, left
Descending colon
Sigmoid colon
Rectum
Efferent Nodal Group*
Subgroup
Superior mesenteric nodes
Superior mesenteric nodes
Superior mesenteric nodes
Superior mesenteric nodes
Superior mesenteric nodes
Left paraaortic nodes
Any level
Category
Abbreviation
Main
Main
Main
Main
Main
Main
SMN
SMN
SMN
SMN
SMN
LPNsr, s, m, i,
LRH
Superior mesenteric nodes
Main
SMN
Preaortic nodes
Inferior mesenteric Main
PANs, m
Left paraaortic nodes
Superior, middle
Main
LPNs, m
Preaortic nodes
Inferior mesenteric Main
PANs, m
Internal iliac nodes
Accessory IIN
Sacral nodes
Accessory SN
* In the small and large intestine, the first echelon nodal group is represented by the juxtaintestinal
(small-bowel) or paracolic (large-bowel) nodes located in the mesenteric border of the organ.
Because of the mobility of these organs, the efferent nodal groups (fixed structures with
reproducible location), rather than the first echelon nodal groups, are represented in the atlas.
822 • Radiology • June 1999
Martinez-Monge et al

9. Figure 4. CT images depict the nodal stations in the abdomen (ab).
variability and nodal interconnection. Another difficult problem is the mobility of
the nodal stations located proximally in
the limbs (inguinal, axilla). The location
of these nodal groups will vary greatly,
depending on simulation positioning. The
cross-sectional images provided in this
atlas were taken during standard CT positioning and may differ from images taken
for radiation planning in special positions. The topograms with bone landmarks may help in correlating the cross
sections provided in this atlas with the
reference points of the actual patients.
Volume 211 • Number 3
SYSTEMATIC VERSUS
NONSYSTEMATIC DESCRIPTION
This atlas is strongly biased toward the
radiation oncology standpoint. Some
nodal areas have been arbitrarily discarded because they are rarely relevant in
radiation oncology. We elected to ignore
the distal and intermediate nodal stations
of the extremities and the nodal stations
of muscular groups. Tumors that spread
to these nodal stations represent a very
small percentage of the overall clinical
practice in radiation oncology. We also
chose not to represent lymph nodal stations pertaining to mobile structures (mesenteric nodes of the small bowel and
most of the large bowel) because of spatial unpredictability. For these anatomic
locations, only the efferent pre- and paraaortic nodal groups have been represented.
ATLAS LIMITATIONS
This atlas cannot be used as a tool to
diagnose or predict nodal involvement. It
Cross-sectional Nodal Atlas for Definition of Clinical Target Volumes • 823

10. only provides a guide to the general anatomic pathways of nodal drainage of the
normal organs shown. It cannot help
forecast individual spread patterns. When
used for 3D virtual clinical target definition, this nodal atlas can help in accurately defining the location of the different nodal stations that are to be included
in the CTV. Deciding which nodal stations should be included in the CTV
depends on the level of spread probability that is clinically assumable for that
specific disease manifestation and the
normal tissue complication probability
for that intended dose level. These two
issues are a matter of clinical judgment
that is beyond the general purpose of this
atlas.
POTENTIAL ADVANTAGES
A nodal atlas allows systematic definition
of CTVs in those clinical situations in
which the irradiation of nodal areas is
clinically relevant, which may facilitate
reliable intercommunication among institutions. The current tendency, however,
is to define CTVs on a nonanatomic basis,
probably due to the lack of a common
anatomic language. Some ongoing radiation therapy protocols have elected to
define the corresponding CTVs as a volume around the GTV. The CTV is then
defined mathematically as a margin
around the GTV. Although reproducible
among institutions, this definition carries the important risk of including in the
CTV some areas with a minimal probability of tumor involvement or areas that
may be at higher risk for treatment toxicity. A nodal atlas allows a better spatial
understanding of the valuable information contained in the surgical pathology
reports. For those patients undergoing
postoperative radiation therapy, the decision-making process essentially depends
on the surgical findings. Improving the
ability to locate high-risk areas (as defined by the surgical information) on a
cross-sectional image must necessarily improve the quality in treatment planning
and delivery. We are currently evaluating
the potential for redesigning radiation
plans on the basis of nodal information
from surgical series and 3D reconstruction with the aid of this atlas.
824 • Radiology • June 1999
TABLE 6
Lymphatic System of the Urinary Tract
Anatomic Site
First Echelon Nodal Group
Right perirenal
tissue
Left perirenal
tissue
Right kidney
Interaortic nodes
Preaortic nodes
Left paraaortic nodes
Preaortic nodes
Right renal hilum nodes
Retroaortic nodes
Left kidney
Left renal hilum nodes
Left paraaortic nodes
Suprarenal glands Renal hilum nodes
Paraaortic nodes
Juxtavertebral nodes
Paraesophageal nodes
Ureter, superior
Paraaortic nodes
segment
Common iliac nodes
External iliac nodes
Ureter, middle
Paraaortic nodes
segment
Common iliac nodes
Ureter, inferior
Common iliac nodes
segment
External iliac nodes
Internal iliac nodes
Bladder
External iliac nodes
Internal iliac nodes
Common iliac nodes
Bulbomembranous External iliac nodes
urethra
Subgroup
Category
Superior
Superior
Superior
Superior
Main
Accessory
Main
Accessory
Main
Superior
Main
Main
Superior
Main
Main
Suprarenal
Main
Inferior
Accessory
Inferior
Accessory
Superior
Main
Accessory
Any level (central, medial) Accessory
Middle
Main
Main
Main
Any level (central, medial) Main
Main
Any level (central, medial) Main
Accessory
Accessory
Middle, inferior (medial) Main
Abbreviation
RANs
PANs
LPNs
PANs
RRH
RANs
LRH
LPNs
RRH, LRH
LPNsr, RPNsr
JVNi
PENi
RPNs, LPNs
CIN
EINs, m, i(c, m)
RPNm, LPNm
CIN
CIN
EINs, m, i(c, m)
IIN
EINs, m, i(c, m)
IIN
CIN
EINm, i(m)
TABLE 7
Lymphatic System of the Male Genital Organs
Anatomic Site
Scrotum
Perineum
Penis, skin
Penis, glans
Penis, corpora cavernosa/penile
urethra
Right testicle/epididymis
First Echelon Nodal Group
Any level
Inferior (medial)
Superior (medial)
Superior (medial)
Right paraaortic nodes
Superior, middle,
inferior
Superior, middle,
inferior
Any level (central)
Preaortic nodes
Left testicle/epididymis
External iliac nodes
Left renal hilum nodes
Left paraortic nodes
Preaortic nodes
Ductus deferens
External iliac nodes
External iliac nodes
Seminal vesicles
Internal iliac nodes
External iliac nodes
Prostate/prostatic
urethra
Subgroup
Superficial inguinal nodes
Superficial inguinal nodes
Superficial inguinal nodes
Superficial inguinal nodes
Deep inguinal nodes
External iliac nodes
Internal iliac nodes
Superficial inguinal nodes
Internal iliac nodes
External iliac nodes
Internal iliac nodes
Sacral nodes
Inferior (medial)
Superior (medial)
Superior
Superior, middle,
inferior
Any level (central)
Superior, middle
(central), inferior
(central, lateral)
Any level (medial,
central)
Any level (central)
Category
Abbreviation
Main
Main
Main
Main
Main
Accessory
Accessory
Main
INs, i(m, l)
INi(m)
INs(m)
INs(m)
INs, i(d)
EINi(m)
IIN
INs(m)
Main
RPNs, m, i
Main
PANs, m, i
Accessory
Main
Main
Accessory
EINs, m, i(c)
LRH
LPNs
PANs, m, i
Accessory EINs, m, i(c)
Main
EINs, m(c), i(c, l)
Main
Main
IIN
EINs, m, i(m, c)
Main
Main
IIN
EINs, m, i(c)
Main
Main
IIN
SN
Martinez-Monge et al

11. Figure 5. CT images depict the nodal stations in the male pelvis (mp).
Volume 211 • Number 3
Cross-sectional Nodal Atlas for Definition of Clinical Target Volumes • 825

12. Figure 6. CT images depict the nodal stations in the female pelvis (fp).
826 • Radiology • June 1999
Martinez-Monge et al

13. Figure 7. Topograms show the levels to which the CT images in Figures 1–6 correspond.
Volume 211 • Number 3
Cross-sectional Nodal Atlas for Definition of Clinical Target Volumes • 827

14. TABLE 8
Gynecologic Lymphatic System
Anatomic Site
Right ovary
First Echelon Nodal Group
Right paraaortic nodes
External iliac nodes
Left renal hilum
Left paraaortic nodes
Preaortic nodes
External iliac nodes
Right fallopian tube Right paraaortic nodes
External iliac nodes
Internal iliac nodes
Left fallopian tube
Left paraaortic nodes
External iliac chain
Internal iliac nodes
Cervix uteri
External iliac nodes
Subgroup
Superior, middle,
inferior
Superior (central)
Left ovary
Corpus uteri
Vagina
Vulva
Clitoris
Greater vestibular
glands
Internal iliac nodes
Sacral nodes
Right paraaortic nodes
Preaortic nodes
Left paraaortic nodes
External iliac nodes
Superficial inguinal nodes
External iliac nodes
Internal iliac nodes
Sacral nodes
Superficial inguinal nodes
Superficial inguinal nodes
Deep inguinal nodes
Superficial inguinal nodes
Finally, the atlas-based 3D definition of
CTVs has the potential to improve the
828 • Radiology • June 1999
Superior
Superior
Any level (central)
Inferior
Superior (central)
Superior
Superior (central)
Superior, middle
(medial, central)
Inferior
Middle
Middle
Superior (central)
Superior (medial)
Any level (central,
medial)
Superior (medial)
Any level
Superior (medial)
Category
Abbreviation
Main
RPNs, m, i
Accessory
Main
Main
Main
Accessory
Main
Accessory
Accessory
Main
Accessory
Accessory
Main
EINs(c)
LRH
LPNs
PANs
EINs, m, i(c)
RPNi
EINs(c)
IIN
LPNs
EINs(c)
IIN
EINs, m(m, c)
Main
Main
Main
Main
Main
Accessory
Accessory
Main
IIN
SN
RPNi
PANm
LPNm
EINs(c)
INs(m)
EINs, m, i(c, m)
Main
Accessory
Main
Main
Main
Main
IIN
SN
INs(m)
INs, i(m, l)
INs, i(d)
INs(m)
therapeutic ratio. Nodal groups with a
very low probability of metastatic involve-
ment can be excluded from the CTV, thus
expanding beam arrangement possibilities and allowing increased treatment intensity. We are also currently evaluating
the volumetric implications (normal tissue dose-volume histograms) of using 3D
virtual simulation with either a nodal
atlas or standard bone landmarks.
The present atlas should aid the radiation oncologist in accurately locating on
cross-sectional images the different nodal
stations that will correspond to the chosen clinical target volume.
Acknowledgments: The authors thank John
Croyle for his help in the preparation of the
graphic matrix of the illustrations and David
Carpenter for editorial assistance.
References
1. International Commission on Radiation
Units and Measurements. Prescribing, recording and reporting photon beam
therapy. ICRU Report 50. Washington, DC:
International Commission on Radiation
Units and Measurements, 1993.
2. Rouviere H. Anatomy of the human lymphatic system. Ann Arbor, Mich: Edwards,
1938.
3. Donini I, Battezatti M. The lymphatic system. Padua, Italy and London, England:
Piccin Medical Books, 1972.
4. Uflacker R. Atlas of vascular anatomy. Baltimore, Md: Williams & Wilkins, 1997.
5. American Joint Committee on Cancer.
AJCC cancer staging manual. 5th ed. Philadelphia, Pa: Lippincott-Raven, 1997.
6. Ellis H, Logan B, Dixon A. Human cross
sectional anatomy. Oxford, England: Butterworth-Heinemann, 1991.
Martinez-Monge et al